Elderwood at Ticonderoga: Catheter Care Failures - NY
That was the explanation a Licensed Practical Nurse gave to inspectors during a complaint investigation completed August 20, 2025. The nurse said they learned about the pulled catheter through the 24-hour report, the unit's standard daily log, and checked on the resident throughout the day. The resident expressed no discomfort. So no call was made.
The nurse knew what the protocol was. During an interview on August 5, they told inspectors directly: when a resident pulls out a Foley catheter, staff should follow physician's orders. If there are no orders, staff should contact the physician and follow their directions. The nurse said both of these things clearly, then explained why neither happened.
The resident wasn't complaining. That was the reason.
A Foley catheter is an indwelling urinary catheter, a tube inserted through the urethra into the bladder to drain urine continuously. When one is pulled out, the balloon that holds it in place inside the bladder is still inflated. The removal can cause trauma to the urethra. Whether or not a patient reports pain in the immediate aftermath doesn't determine whether injury occurred or whether medical evaluation is needed.
The nurse did not call the physician.
When inspectors dug further into the resident's electronic chart, a second problem surfaced. The nurse reviewed the chart during the August 5 interview and told inspectors what they found: there were no physician orders anywhere in the record for the resident's indwelling catheter. None.
The nurse had described what routine catheter care is supposed to look like: cleaning the insertion site, confirming the catheter is intact, recording the color, consistency, and amount of urine. That documentation and that care requires a physician order to be in place. For this resident, it wasn't.
Inspectors attempted to interview the medical provider, listed in the report as Medical Provider #1. Those attempts were unsuccessful.
The inspection was a complaint investigation, meaning someone, whether a resident, family member, or staff, had contacted regulators before inspectors arrived. The report does not identify who filed the complaint or what specifically triggered it. What inspectors documented fell under F0690, the federal deficiency tag covering urinary tract care and catheter management. The level of harm was cited as minimal harm or potential for actual harm, and the violation was noted as affecting few residents.
That classification sits at the lower end of the federal harm scale. It does not mean nothing went wrong.
What the record shows is a resident with an indwelling catheter who had no physician orders governing their catheter care, and who pulled that catheter out without anyone contacting the doctor responsible for their treatment. The nurse who should have made that call knew the standard. They said so themselves, in plain language, to inspectors. Then they explained that they hadn't followed it.
The reason: the resident wasn't complaining.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elderwood At Ticonderoga from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 15, 2026 · Our methodology
ELDERWOOD AT TICONDEROGA in TICONDEROGA, NY was cited for violations during a health inspection on August 20, 2025.
That was the explanation a Licensed Practical Nurse gave to inspectors during a complaint investigation completed August 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.